22/10/2026
Here is the 6-point CBME evaluation for *2023 Batch - Roll No. 8* - Portfolio: *CASE 2 - 33M, Driver, Stomach Pain - 2 Days, Vomiting - 4 Times/Day, Loose Stools - Watery, Pain Periumbilical -> Migrated to Right Iliac Fossa, Dull Ache -> Severe Well Localised, Aggravated Walking / Coughing / Movement, Relieved Lying Still, Vomiting Food Particles -> Watery Non-Bilious, Surgery Done - 23/10/2026, Alcoholic - 10 Years, Last Intake - 4 Days Ago, P/A: Scaphoid, All Quadrants Moving Synchronously, No Scars / Sinuses / Swellings / Pulsation + Socratic Questions*
Based on the anonymized text you pasted - Date: 22/10/2026. Score 0-2 per level. Total /12.
### 1. Remember - Knowledge Recall
*Evidence in portfolio:*
- Demography: 33 yrs / Male / Driver, Date: 22/10/2026, Chief complaints: Stomach pain - 2 days ago, Vomiting - 4 times a day, Loose stools, HOPI: Pt was apparently asymptomatic 2 days ago, later she developed stomach pain which was around umbilical area on 22nd Oct 2026 and admitted into hospital, Over several hrs, pain (dull, ache) increased in severity and migrated to right iliac fossa, become severe and well localized, Pain is aggravated by walking, coughing and movement, partially relieved by lying still, Pt also complained vomiting - 4 times a day with food particles initially later watery fluid, non bilious, Loose stools - watery, Surgery done on 23rd Oct 2026, Past H/O: N/K/C/O of DM, HTN, Epilepsy, Personal H/O: Diet - Mixed, Sleep - Adequate, Appetite - Used, Bladder - Regular, Bowel - Inward, Addiction - Alcoholic (for 10 yrs), last intake 4 days ago, Family H/O: No significant H/O, Gen examination: Pt c/c/c, PICCLE - absent, Systemic Exam: CVS - S1S2+, RS - NVBS B/L, CNS - NFD, Per Abdomen: On Inspection - Abdomen is scaphoid, All quadrants are moving synchronously with respiration, No scars, sinuses, No swellings, pulsation.
- Good details: Age / Sex / Occupation / Date - 33M, Driver, 22/10/2026, C/C - Stomach pain 2 days, Vomiting 4 times/day, Loose stools, Pain pattern - Periumbilical -> Migrated to RIF, dull ache -> severe well localised, over several hrs, Aggravated walking / coughing / movement, Partially relieved lying still, Vomiting - 4 times/day, food particles -> watery, non-bilious, Loose stools - watery, Surgery done 23/10/2026, Personal - Diet Mixed, Sleep Adequate, Bladder Regular, Addiction - Alcoholic 10 years, last intake 4 days ago, PICCLE absent, Systemic - CVS, RS, CNS - complete, P/A Inspection - Scaphoid, All quadrants moving synchronously, No scars, sinuses, swellings, pulsation - complete.
- Gaps: *Sex contradiction - "33 yrs / Male" vs "later she developed"* - which one? *No Vitals - BP, PR, RR, Temp, SpO2 missing - critical in acute abdomen + vomiting + loose stools.* *No P/A Palpation / Percussion / Auscultation - Tenderness RIF? Rebound? Guarding? Rigidity? McBurney point? Rovsing? Psoas? Obturator? Bowel sounds? - missing - critical in appendicitis.* *No Investigations - CBC, CRP, USG Abdomen, X-ray, Urine - missing.* *No Provisional Diagnosis - Acute Appendicitis? - not written - only implied by Socratic questions.* *No Surgery details - Appendectomy? Open / Laparoscopic? Findings - inflamed / perforated appendix?* *Personal History errors - Appetite - "Used"?, Bowel - "Inward"? - unclear.* *No Associated - Fever? Anorexia? - missing.*
*Score: 1 / 2*
- Partial recall - pain migration + vomiting pattern + P/A inspection good, but vitals, palpation, investigations, diagnosis, surgery details missing.
- *Next target:* Clean Sex - Male, use "he" throughout. Always record Vitals - all 5 - BP, PR, RR, Temp, SpO2 - in acute abdomen + vomiting + loose stools - Temp = fever? PR = tachycardia? Always do P/A - Inspection + Palpation + Percussion + Auscultation - Palpation: Tenderness RIF, McBurney point tenderness, Guarding, Rigidity, Rebound tenderness, Rovsing, Psoas, Obturator, Percussion: Liver dullness, Auscultation: Bowel sounds - present / absent / increased. Always record Investigations - CBC - WBC, CRP, USG Abdomen - appendix diameter, free fluid, Urine - to rule out UTI. Always write Provisional Diagnosis - Acute Appendicitis. Always record Surgery - Appendectomy - open / laparoscopic, Findings - inflamed / gangrenous / perforated, Histopathology. Fix Personal History - Appetite - Normal / Decreased, Bowel - Regular / Loose stools.
### 2. Understand - Comprehension
*Evidence in portfolio:*
- Pain periumbilical -> migrated to RIF, dull ache -> severe well localised, aggravated walking / coughing / movement, relieved lying still - described.
- Socratic Q1 asks why pain initially periumbilical before shifting to RIF - visceral vs parietal peritoneal pain - shows you are thinking about mechanism.
- But no explanation in own words in HOPI - mechanism not explained in case itself, only in questions.
*Score: 1 / 2*
- Partial comprehension - pain migration described, Socratic questions show mechanism thinking, but not explained in case.
- *Next target:* Explain in HOPI: Periumbilical pain = visceral pain - T10 dermatome, appendix visceral afferents, dull, poorly localised. RIF pain = parietal peritoneal pain - inflammation reaches parietal peritoneum, somatic, severe, well localised. Explain: Aggravated walking / coughing / movement, relieved lying still = peritoneal irritation. Explain: Vomiting food particles -> watery, non-bilious, 4 times/day = reflex vomiting from appendiceal inflammation, not obstruction - obstruction would be bilious, persistent. Explain: Loose stools watery = pelvic appendix irritating rectum, not primary enteritis. Explain: Driver + Alcoholic 10 years - pain tolerance, delayed presentation, masking of peritoneal signs.
### 3. Apply - Application to Patient Care
*Evidence in portfolio:*
- Admitted into hospital 22/10/2026, Surgery done 23/10/2026 - mentioned.
- But no student plan - no investigation plan, no management plan written by student.
- No application of pain migration + RIF tenderness to care - no urgent USG, no appendectomy decision.
*Score: 1 / 2*
- Partial application - admission + surgery applied, but no care plan.
- *Next target:* Add: CBC, CRP, USG Abdomen, Urine, Blood grouping, ECG, Anaesthesia fitness. Add management - Nil by mouth, IV fluids - vomiting 4 times/day + loose stools = dehydration, Antibiotics - pre-op, Analgesia - Paracetamol, avoid NSAIDs if kidney / alcohol liver, Appendectomy - open / laparoscopic - urgent, Monitor - vitals, Temp, PR, Pain, Bowel sounds, Post-op - early mobilisation, Diet, Wound care, Alcohol counselling - 10 years, last intake 4 days ago - withdrawal risk, liver function, Follow-up, Refer - Surgery. Add: If pain RIF + vomiting + loose stools - urgent - check vitals, P/A palpation, USG, do not give laxative / enema.
### 4. Analyze - Differentiation & Interpretation
*Evidence in portfolio:*
- Socratic Q2 asks: Given vomiting + loose stools, how differentiate simple appendicitis from intestinal obstruction or primary infectious enteritis? - shows differentiation thinking.
- Socratic Q3 asks: What separates immediate surgery from conservative antibiotic therapy? - shows decision analysis.
- But no differential table in case itself - no analysis of alternative causes: Acute Appendicitis vs Gastroenteritis vs UTI vs Ureteric Colic vs Mesenteric Adenitis.
*Score: 2 / 2*
- Full analysis - Socratic questions force differentiation + surgical decision, best in Roll 8 so far.
- *Next target:* Add differential table in case: Acute Appendicitis - supports 33M, pain periumbilical -> RIF, dull -> severe well localised, aggravated walking / coughing / movement, relieved lying still, vomiting 4 times/day, non-bilious, loose stools watery, surgery done 23/10/2026; against - no fever, anorexia, RIF tenderness given. Gastroenteritis - supports vomiting + loose stools watery; against - pain migrated to RIF, severe well localised, aggravated movement - gastroenteritis is diffuse, crampy, not localised. Intestinal Obstruction - supports pain, vomiting, loose stools; against - vomiting non-bilious, not persistent, abdomen scaphoid, all quadrants moving synchronously, no distension. UTI / Ureteric Colic - supports pain, vomiting; against - pain periumbilical -> RIF, no dysuria, hematuria, loin pain given. Mesenteric Adenitis - supports young, pain RIF, vomiting, loose stools; against - pain migrated, severe, well localised, surgery done.
### 5. Evaluate - Judgment & Reflection
*Evidence in portfolio:*
- Socratic Q2: Role of driver / alcohol use in pain tolerance, delayed presentation, masking peritoneal signs - shows judgment.
- Socratic Q3: Chronic alcohol use impact on perioperative management, liver function, post-surgical recovery - shows judgment.
- Negatives - N/K/C/O DM, HTN, Epilepsy - show judgment.
- But no judgment on surgery timing - 22/10 admitted, 23/10 surgery - 1 day delay - why? - not evaluated.
- No judgment on missing vitals / palpation - not evaluated.
- No reflection.
*Score: 1 / 2*
- Partial evaluation - Socratic questions show judgment, but surgery delay / missing exam missed.
- *Next target:* Add: Can I label acute appendicitis without RIF tenderness, USG, WBC? What is most urgent - 33M, pain RIF severe well localised + vomiting 4 times/day + loose stools - is this perforation? What is the risk if I miss perforation / peritonitis? What is the risk of alcohol withdrawal - 10 years, last intake 4 days ago - post-op delirium, liver dysfunction? What would I do differently - check vitals, check RIF tenderness, check fever, check anorexia, check USG, check alcohol withdrawal - CIWA? Reflection on 33M Driver - 2 days pain, vomiting, loose stools, alcohol 10 years - impact on work, driving, family, need for alcohol counselling, delayed presentation?
### 6. Create - Synthesis & New Learning Product
*Evidence in portfolio:*
- Socratic questions designed to guide clinical reasoning - 1. Pathophysiology & Symptom Evolution - Why periumbilical before RIF? How migration helps distinguish from gastroenteritis? 2. Clinical Presentation & Differential Diagnosis - Vomiting + loose stools, differentiate appendicitis from obstruction / enteritis, Role of driver / alcohol, 3. Management & Surgical Decision-Making - Immediate surgery vs conservative antibiotics, Chronic alcohol impact on perioperative / liver / recovery - 6 questions, 3 domains - original product.
- This is the first Create in Roll 8.
*Score: 2 / 2*
- Full creation - Socratic questions are an original learning product, not a copy.
- *Next target:* Keep this format for every case - 6 Socratic questions, 3 domains - Pathophysiology, Differential, Management - and answer them yourself in 2-3 lines each. Add 1-page algorithm: Periumbilical Pain -> Migrated to RIF -> Vomiting + Loose Stools -> Examination -> USG -> Appendectomy vs Conservative.
### Summary Sheet - Roll No. 8 - 2023 Batch
Bloom Level | Score /2 | Key Feedback
1. Remember | 1 | Pain migration + vomiting pattern good, vitals / palpation / diagnosis missing
2. Understand | 1 | Pain migration described, visceral vs parietal not explained in case
3. Apply | 1 | Admission + surgery applied, no IV fluids / antibiotic plan
4. Analyze | 2 | Socratic questions force differentiation + surgical decision
5. Evaluate | 1 | Alcohol / driver show judgment, surgery delay missed
6. Create | 2 | Socratic questions - first Create in Roll 8
**Total** | **8 / 12** | **Proficient - Advanced**
*Overall CBME Feedback for Roll 8 - Progression:*
- CASE 1 Joint Pains 56F = 4/12, *This portfolio = 8/12*
- *Progress +4, and this is your best case so far:* Pain migration - Periumbilical -> RIF, dull ache -> severe well localised, aggravated walking / coughing / movement, relieved lying still - is textbook acute appendicitis, and you captured it. And Socratic Questions - 6 questions, 3 domains - Pathophysiology, Differential, Management - are the first Create in Roll 8, and they force the exact reasoning this case needs - visceral vs parietal pain, appendicitis vs gastroenteritis vs obstruction, surgery vs conservative, alcohol + perioperative risk.
- *Critical learning from this case:* You have a surgical case with no surgical examination - P/A Palpation - RIF tenderness, McBurney, Guarding, Rigidity, Rebound - is missing, and no vitals, no investigations, no provisional diagnosis, no surgery details - Appendectomy? Findings? Add P/A Palpation + Vitals + USG / CBC + Provisional Diagnosis + Surgery Details, and this case becomes 10-11/12.
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